Compliance Nurse Auditor (19.99 Hours a Week or Less, Non-Benefit Bearing) Office of Institutional Compliance

Minimum Qualifications:

Bachelor’s Degree in a related field and four years of related experience.  RN designation with current Texas license required.  Minimum of two years of experience in direct patient care in a hospital setting. 

Preferred Qualifications:

• Ten (10) years of nurse auditing/compliance experience is highly preferred.
• CPC/CPC-H, CHC, CCS, or CCS-P certification.

Job Summary:

To provide clinical support through the performance of audits and reviews of Additional Records Requests (ADRs) and governmental payers denials.  To implement and provide a standardized clinical documentation education program to billing providers and the UTMB workforce as required. To work with the Billing Compliance Director on pre- and post-audit education plans. To assist with the identification of other areas of opportunity for clinical billing compliance and clinical documentation education.

Job Duties:

• Reviews RAC and other governmental payers’ medical records requests, ADRs, and other record requests as required to ensure clinical documentation supports the medical necessity of the services rendered and the corresponding charges were/are billed.
• Investigates denials and recoupments to find the root cause of the problem(s) and formulates action plans as needed.
• Conducts proactive audits as needed in order to minimize and mitigate risks.
• Utilizes medical records and clinical expertise to appeal Recovery Auditor Contractor (RAC)/Medical Administrative Contractor (MAC) denials as needed.
• Develops documentation education programs to address both professional and facility/hospital coding issues.
• Develops departmental documentation education to address issues identified by governmental audits, the Billing Compliance audit team, and other third party payers.
• Assists with analysis of data/reports from compliance monitoring activities to help identify trends, issues, risk areas, and opportunities for coder and provider education.
• Prepares and presents reports summarizing audit and education activities.
• Works with the Billing Compliance Director to develop training methods.
• Maintains current knowledge regarding federal, state, and local compliance guidance, initiatives, work plans, and payer regulations. Ensures that education standards are updated appropriately to reflect regulatory changes.
• Establishes and maintains excellent interdepartmental relationships with clinical and business administration department heads to facilitate cooperation and compliance.
• Formulates alternative solutions to problems, promotes ideas, and obtains acceptance and action on issues resulting from clinical documentation education.

Salary Range:

Actual salary commensurate with experience.

Work Schedule:

This is a casual appointment working 19.99 hours a week or less, not eligible for benefits.